What happens when we swallow?

When we swallow, we transfer food/liquid from our mouth to our stomach. While this seems simple, it actually involves multiple complex manoeuvres spanning voluntary (e.g.: using your teeth to mash crunchy food) and involuntary movements (e.g.: reflexive muscle movement that propels food through the throat).

First, you take food off the fork/spoon using your lips and tongue, and subsequently mould the food into a small ball (bolus) that is suitable for swallowing. Then, your tongue propels the food backwards into your throat (pharynx). In typical swallowing, your wind-pipe (trachea) is protected during swallowing by a flap of muscle called the epiglottis. This stops food going into your lungs. Food then moves down into you food pipe (oesophagus) and finally into your stomach.

What is dysphagia?

Dysphagia is a swallowing disorder characterized by difficulty transferring food/fluids from the mouth to the stomach, and is associated with emotional, cognitive, sensory and/or motor problems (Tanner, 2006). Dysphagia may result in penetration, aspiration or choking:

Penetration: Penetration is the misdirection of food/fluid into the laryngeal vestibule

Choking: Choking happens when food/objects get stuck in the throat and block airflow.

What are the consequences of dysphagia?

Dysphagia can have far-reaching consequences on both patients and their caregivers. Firstly aspiration can result in aspiration pneumonia which often necessitated hospitalisation and can have serious health consequences. Similarly, choking can result in suffocating. If dysphagia is severe, the patient may experience severe weight loss, necessitating non-oral feeding methods like feeding tubes to support nutrition. Your speech and language therapist and dietician may recommend special diets, if needed.

Having difficulties with eating and drinking can cause people embarrassment and reduce their social participation. For example: the patient may not want to go out for dinner because they are embarrassed. Similarly, caregivers may have reduced quality of life because they feel helpless and unable to provide relief to their loved ones.

What are the red flags for dysphagia?

Certain clinical groups are at a higher risk of developing dysphagia than others due to a variety of reasons. We have compiled a list of these below:

The person may have reduced range of motion of structures due to tumour growth, or the results of treatments such as surgery or radiation therapy. Similarly, treatment may cause dry mouth or reduced strength causing the person to need to swallow multiple times

Chen et al., (2001)

Rosenthal, Lewin & Eisbruch (2006)

Nguyen et al., (2004)

Nguyen et al.,(2005)

Caudell et al., (2009)

People with dementia

The person may have motor planning problems which make coordination of swallowing difficult. Cognitive difficulties can result in the person forgetting meals, or forgetting to swallow mouthfuls, increasing the risk of choking

The person may have trouble moving the food through their oesophagus, or the food/liquid may return up their oesophagus as reflux. This can damage tissues in the throat and create a â€œlump in the throatâ€ feeling

Attwood, Smyrk, Demeester & Jones (1993)

DeMeester, Bonavina & Albertucci (1986)

People with mental health issues (e.g.: schizophrenia)

The person may have behavioural issues such as impulsiveness, or may have side effects to medication which makes them drowsy and at risk of choking. They may have co-occurring neurological issues or experience the effects of institutionalisation

The person may experience decreased control of muscles or range of motion issues due to neurological problems. The person may have sensory issues which makes swallowing difficult, also

Price, Jones, Charlton & Allen (1987)

Smithard, Smeeton & Wolfe (2007)

Falsetti et al., (2009)

People who have undergone surgery

Certain surgeries (e.g.: cervical spine surgery) may result in transient or permanent dysphagia in certain cases.

Bazaz, Lee & Yoo (2002)

Riley-III, Skolasky, Albert, Vaccaro & Heller (2005)

Hunter, Swanstrom & Waring (1996)

Lee, Bazaz, Furey & Yoo (2007)

Fogel & McDonnell (2005)

Children who are born with congenital conditions (e.g.: cerebral palsy)

Due to damage to the nervous system, the child may have altered muscle tone or reduced coordination which makes it difficult to swallow or feed safely. Similarly, if the child has cognitive difficulties, this may affect feeding overall.

Rogers, Arvedson, Buck, Smart & Msall (1994)

Calis et al., (2008)

Reilly, Skuse & Poblete (1996)

Mirrett, Roski, Glascott & Johnson (1994)

People taking certain medications (e.g.: sedatives)

Medications may have sedative effects on the central nervous system making it difficult to control muscles. Similarly, it may make the person drowsy, increasing the risk of choking

Stoschus & Allescher (1993)

Regan, Sowman & Walsh (2006)

People who are elderly

People who are elderly may experience reductions in strength which increases risk of dysphagia. Also, with increasing age, the risk of having other conditions which cause dysphagia increases

Marik & Kaplan (2003)

Robbins, Bridges & Taylor (2006)

Logemann, Curro, Pauloski & Gensler (2013)

Similarly, certain signs that you may notice act as red flags for dysphagia.

The list below outlines some of these (please note that this list is not exhaustive):

Sign

Reason

Taking longer than usual to finish a meal

The person may be having trouble chewing/swallowing the food, resulting in longer mealtime

Changing regular diet habits due to difficulty eating

The person may recognise that they are having difficulty eating/swallowing and to avoid embarrassment or visiting the doctor, may change habits subtly

Difficulty chewing

This may be due to changes in muscle function in the jaw or dental issues. The person may have to swallow large pieces of food which can be dangerous

Build-up of food inside mouth

After swallowing, the person may have a build-up of food inside the cheeks/under the tongue. This may be due to a sensory difficulty of not recognizing the food in the mouth or a difficulty with the tongue not being able to collect the food

Nasal regurgitation

This may be due to a motor problem as the muscles cannot direct the food the right way. Also, the sphincter at the top of the oesophagus/food-pipe may be too tight and not letting food go down

Unexplained weight loss

This may indicate that the person is not receiving nutrients from the food they are eating possibly due to structural issues. The person should see their GP regarding this issue

Reflux

This may indicate that food is pocketing in a diverticula/pouch off the oesophagus and then being regurgitated. Otherwise, it may indicate low tone in the sphincters of your oesophagus

Cough before, during and after swallow

This may be due to the food/fluid touching/entering the laryngeal vestibule/wind-pipe and causing irritation

Choking

The person may get food/foreign objects lodged in their throat and not be able to remove this due to constriction/reduced muscle strength

Dry mouth

When a person has a dry mouth, it is more difficult to swallow as they cannot form a moist and cohesive bolus to swallow

Needing to swallow several times per mouthful

This may be normal if the food is particularly hard or crunchy, or if you took a very large mouthful. However, it may indicate reduced muscle strength

Drooling

The person may have reduced muscle strength in the cheeks, tongue and lips, and/or sensory difficulties in recognizing the drool on their face

Cyanosis/turning â€œblueâ€ while eating

This may indicate an inability to coordinate breathing and swallowing and indicates a significant safety risk

Child arching their back

Oftentimes children with swallowing difficulty arch their back to indicate difficulty or discomfort during swallowing

â€œWetâ€ voice

The person may not be able to clear liquids/secretions/food from their laryngeal vestibule causing their voice to sound â€œwetâ€ or â€œbubblyâ€

Recurrent chest infections/aspiration pneumonia

This may indicate that the food/fluids is going into the wind-pipe/trachea and lungs rather than the oesophagus/food pipe

Difficulty managing oral medications

Oral medications such as tablets may be difficult to swallow as they are often large and hard. If they get â€œstuckâ€ in the throat, it may indicate reduced muscular strength

Difficulty maintaining upright posture during feeding

If the person is in a slumped position with their head down/tilted it may cause difficulty directing the bolus appropriately

Ill-fitting dentures

This predisposes the person to difficulties chewing and mashing food appropriately which can lead to swallowing problems

Pain while swallowing

The person may have an infection, a structural problem or difficulties with their oesophagus. Visit your GP in this case

Forgets that food is in their mouth

The person is predisposed to choking/aspiration as they are not prepared to swallow

Child is irritable during feed

This may indicate difficulty swallowing/discomfort on swallowing

Food refusal

This may indicate that the person is aware of swallowing difficulties and does not want to risk eating

Vomiting during/after food

This may indicate a problem with the oesophagus/food pipe or stomach

What do I do if I think I/my loved one has dysphagia?

If you think you or your loved one has some red flags for dysphagia, you should contact your G.P/Public Health nurse.

Alternatively, you can present to your local Accident and Emergency department if symptoms are severe.

Finally, you can contact CATTS Ireland for a consultation on 086 888 2765.